Laserfiche WebLink
WE&J PERMIT APPLICATION RM SITE <br /> SAN JOAQUlN COUNTY MITIGATION <br /> ENVIRONMENTAL HEALTH DEPARTMENT (EHD) UNIT IV <br /> 304 E. Weber, Third Floor, Stockton, CA., 95202 <br /> (209) 468-3449 <br /> NON-REFUNDABLE PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development Title,Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br /> Assessors <br /> WELL Location 23``7 k f7014 JOWdCros,Street 4WAMA W City A j9MA Zip�M& Parcel# <br /> arta` R k. G►n G ty on p� <br /> PROPERTY Own //�� Add /V! Ci Zi Phon __ <br /> C-57 ContractorAbitu�?��.:L�lrse&� Address r✓ .� Ci ;1 Zip Lic# Phone#. 1�6�/C <br /> Consultant/Sub Cntr_A /[a,t•ttP 6-0Tic,0 Address 83 Sfl[tw ISA` City5k4_10/1 Lic#• ( Phone# a�"44 zzLby, <br /> GIS Coordinates:X Y Township Range Section <br /> WORK TO BE PERFORMED: <br /> KNEW WELL AjO N (CPT,GEOPROBE,HYDROPUNCH,HAND-AUGER,OTHER*) 0 DESTRUCTION(choose type below) <br /> JZSOIL BORING# Q OVER-BORE <br /> WELL# 0 PRESSURE GROUT <br /> 'Other: Grout Specifications: <br /> COMMENTS <br /> TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> 0 MONITORING 0 HOLLOW STEM DIA.OF BOREHOLE MULTIPLE CASINGS?0 MULTI-LEVEL?0 WELL CASING DIA: �!. <br /> 0 EXTRACTION 0 AIR HAMMERIDRIVEN CASING THICKNESS' AYA _TYPE OF CASING: 0 STEEL flPVC BOTHER: <br /> 0 VAPOR p MUD ROTARY DEPTH OF GROUT SEAL_ a��TREMIE TYPE TO BE USED: 0 AUGERS RHOSE <br /> 0 AIR SPARGE 1 Ozone XPUSH POINT GROUT SEAL PUMPED: p Yes 0 No (NO E: MAXIMUM FREE-FALL DEPTH IS 30') <br /> 0 SOIL BORING 0 HAND AUGER GROUT SPECIFICATIONS: yr B <br /> B OTHER:_ n OTHE=R APPROX.BORING DEPTH��p _0 BOLTED TRAFFIC BOX or 0 STOVE PIPE <br /> CONDUCTOR CASING PROPOSED? AJ/14 (if YES,list specifications here): <br /> 'COMMENTS: <br /> NOTE: OFFSITE BORINGS REQUIRE ACCESS OR ENCROACHMENT PERMITS. <br /> CALL THE UNIT IV INSPECTOR 48 WORKING HOURS IN ADVANCE FOR ALL REQUIRED INSPECTIONS. <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br /> Count Ordinances, Rules and Regulations, and all applicable California State Laws. <br /> Signed x Title/Company 49 _ &_C�I pq l: <br /> Print Name of a1 (k Ll✓[. Date ZJ <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE, ADD ESS' ( �� <br /> WORK PLAN DATED: 0 � <br /> Application Accepted By / \ Date Issued Ar a <br /> Grout Inspection By DateZI DateI L IJ Final Inspection By Date <br /> Destruction Inspection By Date <br /> COMMENTS I CONDITIONS: <br /> [ACCOUNTING ONLY: AID# <br /> PE CODES FEE INFO AMOUNT REMITTED CHECK# REC'D BY DATE PERMIT SERVICE REQUEST# INVOICE <br /> 35 6 A '9n <br /> C-57 WC--WAIVER— C-57 Letter of Authorization to sign permit Encroachment doc 3/29/02 <br />